Wednesday, July 22, 2009

A question about medical ethics:

We have an 81-year-old patient with a fairly aggressive cancer. She came in yesterday, her son immediately asks to speak to us in the hall. The family is worried she wouldn't deal well knowing she has cancer, and her primary doctor agreed not to tell her and to instead call it an "infection" when talking to her. Giving her appropriate treatment, but hiding the actual diagnosis from her.

The patient has no signs of dementia, seems mentally competent.

The attending agreed to do what the son was asking. So now we're all calling this thing an "infection" and telling her the chemotherapy drugs are "antibiotics".

I find this appalling.

Her son doesn't have medical power of attorney over his mother. I don't know how we can say that she's giving her consent to treatment when she's being lied to about what she's being treated for. I don't know what the son plans to do if the mother finds out what she has, and finds out we've all been in cahoots with her son to lie to her. I don't know what anyone expects we're supposed to do if the "antibiotics" don't work, and she needs some sort of surgical intervention, or more powerful treatment, or how you talk to someone about advance directives when they aren't aware of the gravity of their condition. I don't know how to even really look her in the eye when I talk to her, knowing we're lying about what's going on. I don't know how her son keeps this secret. And I'm pretty sure one of us is bound to slip up and accidentally say something within earshot... and then what? If she gets a roommate, it's going to be awfully confusing if the roommate starts asking what she has, because this isn't the "infection" floor and she's not being seen by the "infection" doctors.

Not to be silly about it, but if this is okay, ethically speaking, then where's the line? What if she really did have just an infection, but her son was worried she wouldn't take that seriously enough, and that in order to scare her into cooperating with treatment, we should tell her she has cancer. Would that be okay? Surely not. At least I assume not! But what's the difference, really?

A mentally competent patient, who's being robbed of her ability to make her own choices about her treatment and her life, and being lied to about her medical condition, just because her family assumes they know what's best. But we're the ones charged with knowing what's best, not her son. At least not without a court order.

But what do I know, I'm just an intern.

Seriously, am I wrong here? Is this standard practice? Is it ethical practice? Is it even legal practice??

27 comments:

Hey ... I think it is very unethical to not tell a 81 yo about her real diagnosis. She isnt suffering from dementia or delirium from what I can tell. And she is still her own person who has the right to know about her medical diagnosis and her medical treatment. Afterall, it is our duty as medical professionals to inform our patients of their diagnosis and treatment options.

--- hmmm really not looking forward to intern year - but ready for 4th year to be over although it just begun

Whoa. This. . .sounds like something worth raising with hospital ethics, if you can track them down, because my inclination would be no - the woman is the MD's patient, not her son, and she has more right to information about her own health than he does.

Unequivocally ethically wrong (and although I'm a British doctor, I imagine this is just as professionally questionable in the US - here it could get you into troulbe with our licencing ody). This questions is actually surprisingly easy to deal with if you don't let it get out of hand. Unfortunately it looks like it already has.

I've been in a couple of similar situations myself, and it's surprisingly straightforward to say "I understand your concern, but you must know I'm required to inform my patient of everything that's going on with her unless she tells me she doesn't want to know". Then with the son present, you point out to the patient that they've had lots of tests, and are going to have some more, then ask "would you like me to tell you all the results, no matter what they turn out to be?"... "What about if it's bad news?". In my experience, they say yes.

Can't use this script now, though. Otherwise you might have to explain why two professionals have been lying to her. Don't envy you.

My dad did this with my mom. She was given 5 months to live and my dad insisted that they doctors never tell her she has cancer, only that she had an infection that needed surgery. She lived on for 9 years, thinking that she was fighting recurrign infections, until a doctor told her that she had cancer and was terminal, then she gave up the fight and died in a couple of weeks.

Very hard call to make, but I know in my mom's case it gave her 9 years and the ability to see a son get married and have 2 grandchilren, both of whom she whould have never seen.

You cannot say that her extra 9 years were because she thought she had recurring infections. There have been many cases that people live beyond the expected time frame, and they were told immediately that they had a terminal illness such as cancer. The patient in question should be told the truth end-of-discussion. If it is so severe, she needs to make sure that a will is in order.

In some cultures it is the norm to withhold a terminal diagnosis from the patient; of course these cultures have a higher likelyhood of having a close and supportive family. This might be the case in this example.

The decision goes against todays philosophy, this does not necessarily mean it is the wrong choice.

These people are her next of kin and although it is harsh to bring it up, they have an interest in her last Will should she decide to alter it.

What is going on is completely unethical, no question about it.

I can't even comment as to what my family did to my grandmother at the end of her life (ending her life) but the doctors were aware of it, as was she, they had consulted their attorneys and as my family had claimed 'religious grounds' they believed their was nothing they could do to stop them.

Completely unethical. If my family or doctor tried a stunt like that I would be livid.

I would say:"Who the F**k do you think you are? You think I can't handle the truth? I can f**king handle it. Let's see how you handle not having an inheritance because you've been cut out for being a douchebag."

The outcome of any medical intervention depends, to some extent, on the mental state of the patient.If the patients family feels that she will be in a better mental state if she doesn't know the truth, then that is a data point for you to go on with.Your interest is in doing whats best for your patient's recovery.If that includes lying to her, I don't see any ethical dilemma in doing so.

Lawyer here (hence the Anon comment, and standard "I am not your lawyer" caveats apply), but yeah -- I agree with the foregoing. Were I hired to represent the estate, you could rest assured that I would sue for malpractice, and I would win -- her son had no power to dictate her medical treatment, and all consents you obtained were invalid and based on false pretenses.

I've gotta say, this is one of the (admittedly rare) cases where ethics and the law match up -- this is, quite simply, wrong, and it exposes you to significant liability. I know attendings can make your life hell, but this could be a great teaching moment -- go to him/her in private and ask for a justification, as well as perhaps a session for your group with the hospital's risk management department on the ethics and efficacy of deceiving patients.

It's entirely possible @anon's mother died so quickly not because she could not handle "having cancer" but rather because she finally found out that her family and children were a bunch of unethical, lying scum thus proving that all her child-rearing effort was ultimately a waste since they'd learned nothing, and especial nothing about ethics or morality!

Maybe she lost the will to live because finally learning the truth, she lost her faith in the core goodness of her own flesh and blood family!

I know you say you are "just an intern", but you are still a doctor. I'd talk about this with the attendings and primary. If that doesn't resolve the obvious unethical and illegal treatment plan, then you need to talk to your residency attendings. And if that doesn't do it, you need to bring it up to the hospital ethics committee. It is very unlikely to get to that. And I also understand that it is very hard to buck the flow here, especially as the intern.

When I was a resident I was never placed into a situation like this. It has come up a few times since I've been in practice, but it's easier to take care of it early than after all the lies have been told.

You know PT or radiology is gonna spill the beans at some point, better take care of it now.

Terrible choice in the first place to go along with this with no first-hand evidence. It's actually impossible to remove yourself fully from lawsuits risk now. Even if you "come clean" the son may well deny all saying you told him. Use Colin's Mitchel's advice and try not to put yourself in such a risky situation in future.

it is absolutely unethical the family have no right to her medical information unless she consents, therefore the doctors are already acting unethically by rfevealing her medical informjation without her written consent. Given that she is mentally competent, the doctor and all complicit with him in keeping her uninformed about her condition are acting in an unethical manner, to say nothing of the blatant disrespect they are showing her by treating her as if she is somehow incompetent. Shame on all of them. PS I am a physician.

As a fellow medicine intern, I'd suggest talking to your program director. No attending, regardless of how important they are, should ask you to do something that puts your license in jeopardy. If your PD isn't responsive, get in touch with the ACGME.

"I've been in this situation a few times. If the patient is able to interact with me directly and understand everything we discuss then I only talk to the patient. If the family is interfering, often unintentionally, I remind them that I am treating the patient, not them. If they still don't get it, I kick them out of the room.

Then I document everything.

I don't care if you are 120 years old, if you can talk to me and understand and make decisions, I'm going to give YOU all the information I have, and we'll make a decision."

You've just got to say: quit f*ing around with this guy, and my medical license. And when your attending says that's not acceptable, tell him if he screws you on your eval you'll have Medical Ethics on his ass. Easy, no?

By not telling her, you're effectively robbing her of the last opportunity to put her affairs in order. What if she'd like to write a will, but hasn't got around to it yet, because she assumes it's nothing serious and she still has time to write a will later? What if she still wants to do one thing in her life (visit with a realtive, go see Paris, etc.) but she hasn't done it yet, because she figures she still has time "later"?

I totally understand where you're coming from. I'm a brand new nurse, still in orientation on a medical/oncology unit. One of my recent patients was an elderly woman who has recently been diagnosed with pancreatic cancer. Her daughters have decided to not tell her. This woman was well into her 80s, but did not suffer from dementia, or anything like that. However, she only spoke Spanish, so they translated everything for her.

When my preceptor told me of the situation, I felt that this was totally wrong and I couldn't believe that I was supposed to go along with it. She just said that I was young, so I would not totally understand. But like I said, I understand where you were coming from.

That´s just... Anon nurse: Really? Damn. The hospital where I did my training and currently work (central regional hospital) has an on-call interpreter service for 170 languages, plus a few that can be flown in. I remember one of my teachers metaphorically murdering an attending for suggesting the use of someone´s husband as their interpreter, rather than waiting 30 minutes.

When it comes to the original post. Shit. I´m glad I´m in nursing. I´ve come across a few sketchy things, but have never had to worry about speaking up. Some nurses and residents have gotten a bit pissy, but since everything gets reported anyway (there´d be a huge hole in the recs if the problems weren´t recorded), I really can´t get into any trouble^^.